Provider Demographics
NPI:1497838577
Name:ORAL MAXILLOFACIAL SURGERY PLLC
Entity Type:Organization
Organization Name:ORAL MAXILLOFACIAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-375-4707
Mailing Address - Street 1:777 N 500 W
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1541
Mailing Address - Country:US
Mailing Address - Phone:801-375-4707
Mailing Address - Fax:
Practice Address - Street 1:777 N 500 W
Practice Address - Street 2:SUITE 102
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1541
Practice Address - Country:US
Practice Address - Phone:801-375-4707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT64166OtherPEHP